Provider Demographics
NPI:1255306668
Name:TETREAULT, AMANDA LYNN (MSPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:TETREAULT
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1780 BEACON ST
Mailing Address - Street 2:#1
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-2030
Mailing Address - Country:US
Mailing Address - Phone:617-974-2980
Mailing Address - Fax:
Practice Address - Street 1:1101 BEACON ST
Practice Address - Street 2:STE 5E
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5587
Practice Address - Country:US
Practice Address - Phone:617-232-6633
Practice Address - Fax:617-232-6832
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17393225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist